Relationship between Self-Report and Proxy Ratings on Assessed Personal Quality of Life-Related Outcomes

The use of proxy measurement of internal states in people with intellectual disability: A scoping review

BACKGROUND

The measurement of internal states of people with an intellectual disability is challenging. Given these difficulties, proxy respondents are sometimes used. However, the literature provides some caution about the validity of the use of proxy respondents.

AIMS

This review aims to identify the available evidence regarding the use of proxy respondents in the measurement of internal states of people with intellectual disabilities.

METHOD

The Arksey and O'Malley scoping review framework was used for this review, refined with the Joanna Briggs Institute Methodology.

RESULTS

Results indicate there are some differences in the findings reported with respect to the efficacy of the use of proxy respondents. These may be due to a number of inconsistencies and weaknesses in examinations of their utility.

CONCLUSIONS

If proxy-reports are to be useful in understanding the internal states of people with intellectual disability, researchers need to address the shortcomings revealed by this review.

Associations between Social Experiences and Psychological Health for Autistic Youth with Low IQ

PURPOSE

Social experiences are consistently associated with psychological health among autistic individuals. However, most extant studies on this topic exclude individuals with autism who have lower IQ or are otherwise unable to self-report. The current study addresses this gap by examining associations of negative peer experiences and social participation with psychological health among autistic youth with low IQ.

METHODS

An online survey was collected from 268 parents of autistic adolescents and adults ages 15-25. Negative peer experiences included measures of peer victimization and being ignored. Social participation was assessed by the amount of participation and parents' perceptions of whether their youth felt the amount of participation was meeting their needs. Psychological health was assessed by parents' report of their youth's psychological quality of life, as well as whether they felt their son/daughter was currently depressed.

RESULTS

Results suggested low rates of social participation in this sample, with relatively high rates of being ignored. Regression analysis found that lower rates of peer victimization and more activities in which parents perceived that the amount of time was meeting their youth's needs was associated with higher psychological quality of life and lower likelihood that parents felt their son/daughter was depressed.

CONCLUSION

Though youth with autism and low IQ are often excluded from interventions aimed at improving social experiences, these findings suggest that promoting positive social experiences and ameliorating negative ones might be an avenue to improving psychological health in this group.

Adapting the EQ-5D-3L for adults with mild to moderate learning disabilities

BACKGROUND

Approximately 1.5 million adults in the UK have a learning disability. The difference between age at death for this group and the general population is 26 years for females and 22 years for males. The NHS Long Term Plan (January 2019) recognises learning disabilities as a clinical priority area. People with a learning disability are often excluded from research by design or lack of reasonable adjustments, and self-reported health status/health-related quality of life questionnaires such as the EQ-5D are often not appropriate for this population. Here, we systematically examine the EQ-5D-3L (its wording, content, and format) using qualitative methods to inform the adaption of the measure for use with adults with mild to moderate learning disabilities.

METHODS

Think-aloud interviews with carers/advocates of learning-disabled adults were undertaken to explore the difficulties with completing the EQ-5D-3L. Alternative wording, language, structure, and images were developed using focus groups, stakeholder reference groups, and an expert panel. Data analysis followed a framework method.

RESULTS

The dimensions and levels within the EQ-5D-3L were deemed appropriate for adults with mild to moderate learning disabilities. Consensus on wording, structure, and images was reached through an iterative process, and an adapted version of the EQ-5D-3L was finalised.

CONCLUSION

The EQ-5D-3L adapted for adults with mild to moderate intellectual/learning disabilities can facilitate measurement of self-reported health status. Research is underway to assess the potential use of the adaptation for economic evaluation.

Measuring quality of life of adults with intellectual disabilities: Psychometric evaluation of the personal outcomes scale in the United Kingdom

BACKGROUND

The Personal Outcomes Scale (POS) is a scale developed to measure quality of life of adults (18+) with intellectual disability. Previous studies have reported good fit for Spanish and Portuguese language versions of POS.

AIMS

This study aimed to evaluate the factor structure of the English language version of POS when used to measure the quality of life of adults (18+) with intellectual disability in the UK.

MATERIALS AND METHODS

Analysis was conducted on POS data from 310 adults with an intellectual disability. First and second order factor models and multi-level models were used to assess fit.

RESULTS

There was poor fit to the data for all tested models. We estimated that 23% of variance in POS scores was accounted for by interviewer cluster.

DISCUSSION

This was the first UK-based evaluation of POS and our data did not confirm the factor structure of the POS measure. The identification of systematic variability within the dataset indicates that inter-rater reliability is a potential limitation of the POS tool.

CONCLUSION

Further research is needed to investigate inter-rater reliability of POS interviewers and to explore factor structure.

Health support of people with intellectual disability and the crucial role of support workers

BACKGROUND

People with intellectual disability have a poorer health status than the general population. In The Netherlands, support workers play a key role in meeting health support needs of people with intellectual disability. Research on how people with intellectual disability and their support workers experience the support worker's role in preventing, identifying, and following up health needs of people with intellectual disability is scarce. To enhance health support of people with intellectual disability it is crucial that we understand how health support is delivered in everyday practice. Therefore, this study investigated experiences of people with intellectual disability and support workers with the health support of people with intellectual disability.

METHOD

Data collection consisted of six focus group (FG) discussions with between four and six participants (N = 27). The FGs consisted of three groups with support workers (n = 15), two groups with participants with mild to moderate intellectual disability (n = 8), and one group with family members as proxy informants who represented their relative with severe to profound intellectual disability (n = 4). The data was analysed thematically on aspects relating to health support.

RESULTS

We identified three main themes relevant to the health support of people with intellectual disability: 1) dependence on health support, 2) communication practices in health support, and 3) organizational context of health support. Dependence on health support adresses the way in which support workers meet a need that people with intellectual disability cannot meet themselves, and communication practices and organizational context are identified as systems in which health support takes place.

CONCLUSION

This study investigated experiences with the health support of people with intellectual disability from the perspectives of people with intellectual disability and support workers. We discuss the dependence of people with intellectual disability and the complexity of health support in everyday practice. We provide practical implications that can strengthen support workers in the provision of health support for people with intellectual disability in everyday practice. The findings of this study emphasize the need for intellectual disability care-provider organizations to establish policies around consistency in support staff to make it easier to identify and follow up health needs, and an environment where support staff can develop their expertise concerning communication practices, lifestyle choices, and identifying and following up health needs.

No ordinary adult life: Living conditions from the perspective of adults with intellectual disabilities

This study focuses on the subjective experience of the living conditions of adults with intellectual disabilities as related to the Uppsala Quality of Life model (UQoL2). Eleven semi-structured interviews were conducted to study issues raised by people with intellectual disabilities. Study participants had their own home, either in an ordinary dwelling or group home. The findings show that the dependence on support in daily life infringes on the sense of adult social status and control of life. Staff and family had a mandate to define Quality of Life, which countered the possibilities of a life based on the preferences of those with intellectual disabilities. Knowledge about factors that affect living conditions, one of the social determinants of health, has implications for public health in general and the development of society's efforts for people who are in lifelong dependence on support and service from others.

Quality of Life in Individuals with Intellectual and Developmental Disabilities: The Congruency Effect between Reports

Assessing quality of life (QoL) is important to provide personalized and individualized support plans with the purpose of improving personal outcomes. Based on the conceptual model of QoL, the aim of this study was to assess the congruence between the perceptions of institutionalized individuals with intellectual and developmental disabilities (IDD) and the perception of a third party, regarding QoL. Forty-two individuals participated in this study, including twenty-one with mild to severe IDD and their family members/caregiver/reference technician, who responded to the Personal Outcomes Scale (Portuguese version). Significant differences (p < 0.05) were found between reports in the personal development (t = -2.26; p = 0.024), emotional well-being (t = -2.263; p = 0.024), physical well-being (t = -2.491; p = 0.013) and total QoL (t = -2.331; p = 0.02). The results further show that most third-party reports tend to undervalue the QoL of the individual with IDD, and that there is no congruence in any of the QoL domains. The inclusion of self-reports in the QoL assessment is important. In addition to the assessment of third-party reports, the process of making decisions appropriate to the context and individual characteristics is equally important. On the other hand, the inclusion of third-party reports is an opportunity to promote communication among all stakeholders, recognize and discuss differences, and promote QoL, not only of individuals with IDD, but also of families.

Quality of life in adults with Down syndrome: A mixed methods systematic review

BACKGROUND

As the life expectancy of adults (aged ≥ 18 years) with Down syndrome increases for a plethora of reasons including recognition of rights, access, and technological and medical advances, there is a need to collate evidence about their quality of life.

OBJECTIVE

Using Schalock and Verdugo's multidimensional quality of life assessment model, this systematic review aimed to identify, synthesise and integrate the quantitative and qualitative evidence on quality of life in adults with Down syndrome via self-and proxy-reporting.

METHODS

Five databases were systematically searched: MEDLINE, CINAHL, PsycINFO, Scopus, and Web of Science to identify relevant articles published between 1980 and 2022 along with grey literature and reference lists from relevant studies. A mixed methods systematic review was performed according to the Joanna Briggs Institute methodology using the convergent integrated approach. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Thirty-nine studies were included: 20 quantitative, 17 qualitative, and 2 mixed methods studies. The synthesised findings were grouped into the 8 core domains of quality of life: personal development, self-determination, interpersonal relations, social inclusion, rights, emotional, physical and material well-being. Of the 39 studies, 30 (76.92%) reported on emotional well-being and 10 (25.64%) on rights. Only 7 (17.94%) studies reported that adults with Down syndrome have a good quality of life centred around self-determination and interpersonal relations. Most adults with Down syndrome wanted to become more independent, have relationships, participate in the community, and exercise their human rights. Self-reported quality of life from adults with Down syndrome was rated higher than proxy reported quality of life. Discrepancies in quality of life instruments were discovered.

CONCLUSION

This review highlighted the need for a better systematic approach to improving the quality of life in adults with Down syndrome in targeted areas. Future research is required to evaluate self-and proxy-reporting methods and culture-specific quality of life instruments that are more appropriate for adults with Down syndrome. In addition, further studies should consider including digital assistive technologies to obtain self-reported quality of life data in adults with Down syndrome.

INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS REGISTRATION NUMBER

CRD42019140056.

Changes in the quality of life of persons with profound intellectual and multiple disabilities following community transition: A Canadian study

BACKGROUND

The goal of this research study was to measure changes in the quality of life (QoL) of adults with profound intellectual and multiple disabilities (PIMD) and complex care needs following their transition from a large institutional residence to smaller community homes in Central Canada.

METHOD

A pre- post-transition quasi-experimental time-series longitudinal study design was implemented to measure the impact of community transition on the QoL of study participants. QoL was assessed in eight domains (self-determination; emotional, physical, and material wellbeing; rights; personal development; social inclusion; and interpersonal relations) by proxy at two time points (Time 1: pre-transition and Time 2: at least 6 months post-transition) using the standardized tool San Martin Scale. The study group included 33 persons with PIMD and complex care needs (20 men [60%] and 13 women [40%]) aged 24-55 years (M = 42.52; SD = 8.07). Paired-samples t-test was conducted to determine significant changes in the QoL of study participants following their community transition.

RESULTS

Between pre- and post-transition, study participants experienced significant improvements in all the eight domains of QoL evaluated as well as in global QoL. Mean differences ranged from 5.67 (SD = 5.16, t₍₃₂₎ = 6.31, p = .001) for rights to 1.73 (SD = 3.10, t₍₃₂₎ = 3.19, p = .003) for physical wellbeing. Mean global QoL improved significantly from 99.97 (SD = 16.54) pre-transition to 120.42 (SD = 10.54) post-transition (M_diff = 17.55, t₍₃₂₎ = 6.69, p = .001).

CONCLUSIONS

This longitudinal study provides evidence of improved QoL for persons with PIMD following deinstitutionalization.

Proxy-report in individuals with intellectual disability: A scoping review

BACKGROUND

Views can be collected from individuals (self-report) or others on their behalf (proxy-report).

OBJECTIVE

We aimed to review the literature on methods and statistical approaches used to evaluate observer versus self-report responses from individuals with intellectual disability or Down syndrome.

METHODS

A series of key questions related to statistical approaches and data collection methods were formulated a priori to inform the search strategy and review process. These addressed the topics of self-report in individuals with intellectual disability, including Down syndrome. Using the National Library of Medicine database, PubMed, detailed literature searches were performed. The quality of available evidence was then evaluated, the existing literature was summarised, and knowledge gaps and research needs were identified.

RESULTS

Fifty relevant original articles were identified which addressed at least one key question. Study details, including: research design, internal validity, external validity, and relevant results are presented. Review of studies of individuals with intellectual disability which used a variety of statistical approaches showed mixed agreement between self-report and proxy-report.

CONCLUSION

Few studies identified to-date have used self-report from individuals with Down syndrome, but lessons from the existing intellectual disability literature can guide researchers to incorporate self-report from individuals with Down syndrome in the future.

Development and psychometric assessment of a psychological well-being instrument for adults with mild intellectual disability or borderline intellectual functioning

BACKGROUND

Measuring eudaimonic well-being is important to gain a complete picture of the well-being of individuals with mild intellectual disabilities or borderline intellectual functioning (MID-BIF), but there is no measurement instrument available for this population coding for multiple dimensions of eudaimonic well-being.

AIMS

The current study developed and piloted a new instrument coding for eudaimonic well-being in individuals with MID-BIF.

METHODS AND PROCEDURES

The instrument (SPWB-ID) was adapted from Ryff's scales of psychological well-being, including subscales addressing purpose in life, environmental mastery, positive relationships, self-acceptance, personal growth, and autonomy. Adaptations were based on the literature and interviews with people with MID-BIF and experts in the field. The SPWB-ID was piloted among 103 adults with MID-BIF.

OUTCOMES AND RESULTS

The trimmed version of the SPWB-ID showed sufficient to good internal consistency and test-retest reliability. Hypothesis testing for construct validity suggested the subscales of the SPWB-ID measured well-being, showing moderate to high correlations with quality of life, and differences in eudaimonic well-being between participants with and without clinically relevant depression scores.

CONCLUSIONS AND IMPLICATIONS

The SPWB-ID reliably measures eudaimonic well-being in individuals with MID-BIF. This enables support providers to collect information on eudaimonic well-being, providing input for person-centred care and support for individuals with MID-BIF.

Assessing the relative importance of key quality of life dimensions for people with and without a disability: an empirical ranking comparison study

Background

In economic evaluation, the quality of life of people with a disability has traditionally been assessed using preference-based instruments designed to measure and value quality of life. To provide robust measurement of the effectiveness of programs designed to improve the quality of life of people living with a disability, preference-based measures need to be sufficiently sensitive to detect incremental changes in the quality of life dimensions that are most important to people who have a disability. This study sought to explore whether there was a difference in the ranked order of importance of quality of life dimensions between people with a disability and people without a disability.

Methods

An online survey was developed and administered Australia wide. The first sample (n = 410) comprised adults (aged ≥ 18 years) with a disability (n = 208) and family carers of person/s with a disability who were asked to respond on behalf of the person with a disability (n = 202). The second sample included adults without disability (n = 443). Respondents were asked to rank the importance of 12 quality of life dimensions extracted from the content of established preference-based quality of life measures (EQ-5D, AQoL and ASCOT).

Results

People with a disability placed relatively higher importance on broader quality of life dimensions (e.g. Control, Independence, Self-care) relative to health status focused dimensions (e.g. Vision, Hearing, Physical mobility). This distinction was less differentiable for those ‘without a disability’. The biggest differences in ranked importance of dimensions were in: Vision (‘with disability’ = 10th, ‘without disability’ = 4th), Self-care (‘with disability’ = 3rd, ‘without disability’ = 7th) and Mental well-being (‘with disability’ = 6th, ‘without disability’ = 2nd).

Conclusions

The relative importance of quality of life dimensions for people with a disability differs to people without a disability. Quality of life is a key outcome for economic evaluation and for assessing the impact of disability care policy and practice in Australia and internationally. It is important that the effectiveness of interventions is measured and valued in ways which are fully reflective of the quality of life preferences of people with a disability.

Impact of Different Pairings of Respondents on Scores on the Supports Intensity Scale-Adult Version (SIS-A)

This secondary analysis examined the impact of respondent-level factors on scores on the Supports Intensity Scale-Adult Version (SIS-A) to determine if there were patterns of differences in SIS-A scores based on the number of respondents and the pairings of respondents that were included in SIS-A interviews. Results indicated that having fewer respondents led to a greater variability in SIS-A scores whereas having more respondents led to higher mean, overall support need scores. When respondents included an adult with intellectual disability (ID) the mean score was significantly lower. However, there were complex influences of pairing an adult with ID with either a professional or family member on SIS-A scores. Implications for administering and using the SIS-A are discussed.

Interrogating and Reflecting on Disability Prevalence Data Collected Using the Washington Group Tools: Results from Population-Based Surveys in Cameroon, Guatemala, India, Maldives, Nepal, Turkey and Vanuatu

The Washington Group (WG) tools capture self-reported functional limitations, ranging from 6 domains in the Short Set (SS) to 11 in the Extended Set (ESF). Prevalence estimates can vary considerably on account of differences between modules and the different applications of them. We compare prevalence estimates by WG module, threshold, application and domain to explore these nuances and consider whether alternative combinations of questions may be valuable in reduced sets. We conducted secondary analyses of seven population-based surveys (analyses restricted to adults 18+) in Low- and Middle-Income Countries that used the WG tools. The prevalence estimates using the SS standard threshold (a lot of difficulty or higher in one or more domain) varied between 3.2% (95% Confidence Interval 2.9-3.6) in Vanuatu to 14.1% (12.2-16.2) in Turkey. The prevalence was higher using the ESF than the SS, and much higher (5 to 10-fold) using a wider threshold of "some" or greater difficulty. Two of the SS domains (communication, self-care) identified few additional individuals with functional limitations. An alternative SS replacing these domains with the psychosocial domains of anxiety and depression would identify more participants with functional limitations for the same number of items. The WG tools are valuable for collecting harmonised population data on disability. It is important that the impact on prevalence of use of different modules, thresholds and applications is recognised. An alternative SS may capture a greater proportion of people with functional domains without increasing the number of items.

Quality of Life: Changes in Self-Perception in People with down Syndrome as a Result of Being Part of a Football/Soccer Team. Self-Reports and External Reports

The hypothesis posed was whether being part of a football/soccer team influenced the quality of life (QL) of the people who participated in it since their perception of themselves is enhanced by factors, such as self-determination, social inclusion, emotional well-being, physical well-being, material well-being, rights, personal development, and internal relationships. The objective was to evaluate the QL of people with Down Syndrome (DS) using their self-perception (n = 39) and the perception of the informants (family members, teachers) (n = 39). The KidsLife-Down Scale, with a few modifications, was used. In general, differences of opinion between the subgroups of participants with DS and informants showed that results were higher in terms of perception for participants in the DS subgroup. Scores for all variables were higher for those participants with DS who said they did engage in practicing competitive football/soccer. Although the perception of informants provides a great deal of information regarding the QL of participants with DS, participants with DS should also be involved in the evaluation process and their self-perceptions taken into account. It is not participating in a football team that causes the conclusions of the study, but training (which includes the friendly matches that are played), the cause correlated with the improvements detected in the athlete’s DS.

Psychometric properties of a brief self-reported health-related quality of life measure (HRQoL-IDD) for persons with intellectual and developmental disabilities

Background

To encourage self‐determination and address health disparities among persons with intellectual and developmental disabilities, clinicians and researchers rely on self‐reported measures like health‐related quality of life (HRQoL). This study evaluated the psychometric properties of a theory‐driven self‐reported HRQoL measure for adults requiring mild to moderate support related to intellectual and developmental disabilities.

Method

224 volunteers completed 42 quality of life items developed with extensive input from persons with intellectual and developmental disabilities, family members/caregivers, and providers. The 5‐point Likert scale format with visual images of fluid‐filled cups represented the range of responses.

Results

Exploratory and Unrestricted Factor Analyses yielded 16 HRQoL items with 4 subscales: Functional Well‐Being, Emotional Well‐Being, Social Well‐Being, and Healthy Decision‐making. The HRQoL‐IDD explained 62.8% of variance, had satisfactory internal consistency (0.73–0.83), stability of reponses, and reading level (2nd grade, ages 7‐8).

Conclusions

The HRQoL‐IDD is a promising measure of self‐reported HRQoL for use in community‐based settings for persons requiring mild to moderate support related to intellectual and developmental disabilities.

Is it feasible to assess self-reported quality of life in individuals who are deaf and have intellectual disabilities?

PURPOSE

There is consensus that Quality of Life (QOL) should be obtained through self-reports from people with intellectual Disability (ID). Thus far, there have been no attempts to collect self-reported QOL from people who are deaf and have ID.

METHODS

Based on an established short measure for QOL (EUROHIS-QOL), an adapted easy-to-understand sign language interview was developed and applied in a population (n = 61) with severe-to-profound hearing loss and mild-to-profound ID. Self-reports were conducted at two time points (t₁ and t₂), 6 months apart. The Stark QOL, an established picture-based questionnaire, was also obtained at t₂ and three Proxy ratings of QOL (from caregivers) were conducted for each participant at t₁.

RESULTS

Self-reported QOL was successfully administered at both time points for 44 individuals with mild and moderate ID (IQ reference age between 3.3 and 11.8 years). The self-reports showed sufficient test-retest reliability and significant correlations with the Stark QOL. As anticipated, self-reported QOL was higher than proxy-reported QOL. Test-retest reliability and internal consistency were good for self-reported QOL.

CONCLUSION

Reliable and valid self-reports of QOL can be obtained from deaf adults with mild-moderate ID using standard inventories adapted to the linguistic and cognitive level of these individuals.

The predictors of proxy- and self-reported quality of life among individuals with acquired brain injury

PURPOSE

Acquired brain injury (ABI) diminishes quality of life (QoL) of affected individuals and their families. Fortunately, new multidimensional instruments such as the calidad de vida en daño cerebral (CAVIDACE) scale are available. However, differences in self- and proxy-reported QoL remain unclear. Therefore, this study examined these differences and identified predictors of QoL among individuals with ABI.

MATERIALS AND METHODS

This cross-sectional study comprised 393 adults with ABI (men: 60%; M_age = 54.65, SD = 14.51). Self-, family-, and professional-reported QoL were assessed using the CAVIDACE scale. Other personal and social variables were assessed as predictors of QoL.

RESULTS

Professionals had the lowest QoL scores (M = 1.88, SD = 0.45), followed by family members (M = 2.02, SD = 0.44) and individuals with ABI (M = 2.10, SD = 0.43). Significant differences were found for almost all QoL domains, finding the highest correlations between family and professional proxy measures (r = 0.63). Hierarchical regression analysis revealed that sociodemographic, clinical, rehabilitation, personal, and social variables were significant predictors of QoL.

CONCLUSIONS

It is necessary to use both self- and proxy-report measures of QoL. Additionally, the identification of the variables that impact QoL permits us to modify the interventions that are offered to these individuals accordingly.Implications for rehabilitationAcquired brain injury (ABI) causes significant levels of disability and affects several domains of functioning, which in turn can adversely affect quality of life (QoL).QoL is a multidimensional construct that is affected by numerous factors: sociodemographic, clinical, personal, social, etc; and also, with aspects related to the rehabilitation they receive after ABI.Rehabilitation programs should address the different domains of functioning that have been affected by ABI.Based on research findings about the QoL's predictors, modifications could be made in the rehabilitation process; paying special attention to the depressive- and anosognosia process, as well as the importance of promoting social support, community integration, and resilience.

Identifying Predictors for Enhanced Outcomes for People With Intellectual and Developmental Disabilities

People with intellectual and developmental disabilities (IDD) often rely on Medicaid-funded services and supports to facilitate their daily living. The financial investment for these services is significant, yet little work has been conducted to understand how these investments affect life outcomes. This pilot study used a novel data integration approach to offer initial insights about how Medicaid expenditures relate to outcomes using Medicaid claims data, results of the National Core Indicators consumer survey, and data from the Supports Intensity Scale (SIS). Findings suggested that subpopulations of people with IDD who also had high behavioral needs or high medical needs had significantly higher expenditures than individuals with more typical SIS-assessed support needs. Regression analyses suggested mixed outcomes based on the factors we considered, including a finding that people with IDD who lived in sponsored residential care homes were more likely to engage in inclusive activities in the community than those who lived in larger congregate settings, or those who lived in a family home. Results of this pilot, when brought to scale, will be useful in examining the performance of state IDD service systems over time.

Impact of the intellectual disability severity in the Spanish Personal Outcomes Scale

BACKGROUND

The interest in measuring quality of life (QoL) in persons with intellectual disability (ID) has brought about a number of QoL measurements for this population. These measurements need to address two issues that have contributed to enhancing the current instruments. First, the necessity to develop measures with adequate psychometric properties, which has been discussed in recent studies, and second, the agreement between experts in analysing objective and subjective perspectives, as well as the use of self-report to include the participation of the person with ID. The question that we set out to investigate in this paper is whether the measurements function properly for the person with ID, independent of their level of severity. We used the Spanish version of the Personal Outcomes Scale, as it is a psychometrically sound instrument and includes three sources of information (the person with ID, a professional and a family member).

METHOD

The sample was composed of 529 persons with ID (296 men, representing 55.95% of the total sample, and 233 women, with M_age  = 35.03, SD = 10.82) from several regions of Spain, along with their professional of reference and a family member. The severity variable was estimated for each item based on estimations of differential item functioning.

RESULTS

The results showed that several items were undervalued by the assessments if the severity of the ID was greater. Mainly, this difference was observed in the assessments by professionals and in the dimensions of rights, personal development and self-determination.

CONCLUSIONS

This paper focuses on the uses and interpretations of the results of the QoL measurements in the Personal Outcomes Scale. The results indicate that, in our sample, when people with high levels of ID are assessed, the functioning of some items are affected by the severity of this disability. For correct use, these items must be interpreted on the basis of the results obtained. Additionally, it is necessary to thoroughly review the QoL indicators for persons with severe or profound ID.

Identifying People With Intellectual and Developmental Disabilities in National Population Surveys

Public health and policy planning for adults with intellectual and developmental disabilities (IDD) is imperiled by the lack of ongoing national surveillance data on prevalence and health status. In 2018, the Administration on Intellectual and Developmental Disabilities appointed a workgroup of representatives from key federal agencies and national experts to recommend strategies to improve prevalence estimates and health surveillance for people with IDD. This article presents the workgroup findings on the availability of prevalence and health surveillance data for adults with IDD and suggested items that could identify respondents with IDD on national surveys with special attention to modifications in the National Health Interview Survey. We identify core constructs that must be measured to identify sample members with IDD in population surveys, and additional constructs which, if measured, would support more comprehensive identification of sample members and enhance ongoing surveillance of the health status, outcomes, and unmet needs of this population. We conclude with a brief review of methodological considerations to improve IDD national surveillance including cultural and linguistic sensitivity and the inclusion of U.S. territories in national surveillance protocols.

Dimensionality and internal structure of the Colombian version of the INICO-FEAPS quality of life scale

BACKGROUND AND OBJECTIVE

Measuring quality of life (QoL) in people with intellectual disabilities (IDs) can help organisations and practitioners to implement evidence-based practices and develop person-centred planning and individualised supports. There is no reliable and valid instrument for assessing QoL in people with ID in Colombia. We investigated the internal structure of the Colombian version of the INICO-FEAPS scale and tested whether the scale identified the eight interrelated domains of the QoL conceptual framework originally described by.

METHOD

Data were collected from 602 adults with moderate levels of ID and respective proxies, who completed the self-report and the report by other scales, respectively. Five measurement models were tested through confirmatory factor analysis.

RESULTS

The eight correlated dimension model showed the best fit to the data. Reliability and convergent validity of the indicators were satisfactory in both versions of the scale (self-report and proxy report).

CONCLUSIONS

This study contributes to research on QoL measurement by providing the first empirical evidence regarding the dimensionality, internal structure and psychometric properties of the Colombian version of the INICO-FEAPS scale. Moreover, the study presents the first adaptation of a specific QoL scale for people with ID in Colombia, which may in the future be useful for implementing evidence-based practices and developing person-centred support plans.

Item response theory analysis applied to the Spanish version of the Personal Outcomes Scale

BACKGROUND

The study of measurements of quality of life (QoL) is one of the great challenges of modern psychology and psychometric approaches. This issue has greater importance when examining QoL in populations that were historically treated on the basis of their deficiency, and recently, the focus has shifted to what each person values and desires in their life, as in cases of people with intellectual disability (ID). Many studies of QoL scales applied in this area have attempted to improve the validity and reliability of their components by incorporating various sources of information to achieve consistency in the data obtained. The adaptation of the Personal Outcomes Scale (POS) in Spanish has shown excellent psychometric attributes, and its administration has three sources of information: self-assessment, practitioner and family. The study of possible congruence or incongruence of observed distributions of each item between sources is therefore essential to ensure a correct interpretation of the measure. The aim of this paper was to analyse the observed distribution of items and dimensions from the three Spanish POS information sources cited earlier, using the item response theory.

METHOD

We studied a sample of 529 people with ID and their respective practitioners and family member, and in each case, we analysed items and factors using Samejima's model of polytomic ordinal scales.

RESULTS

The results indicated an important number of items with differential effects regarding sources, and in some cases, they indicated significant differences in the distribution of items, factors and sources of information.

CONCLUSIONS

As a result of this analysis, we must affirm that the administration of the POS, considering three sources of information, was adequate overall, but a correct interpretation of the results requires that it obtain much more information to consider, as well as some specific items in specific dimensions. The overall ratings, if these comments are considered, could result in bias.

Developing a Health-Related Quality-of-Life Measure for People With Intellectual Disability

Using principles of community-based participatory research we developed a new theory-based measure of health-related quality of life (HRQOL) for individuals with intellectual disability (ID). We recruited adults with ID (n = 129) to take part in interviews and review successive versions of HRQOL items. Critical input about content and understandability shaped the items, as did input from four focus groups of parents/caregivers (n = 16) and representative stakeholders from community-based agencies (n = 7). The resulting HRQOL measure, called the HRQOL-IDD, contains 42 items. The response format depicts a gradient of fluid-filled cups ("none" to "full") to represent frequency of experience of each item on a 5-point scale.

Developing a proxy version of the Adult social care outcome toolkit (ASCOT)

BACKGROUND

Social care-related quality of life is a key outcome indicator used in the evaluation of social care interventions and policy. It is not, however, always possible to collect quality of life data by self-report even with adaptations for people with cognitive or communication impairments. A new proxy-report version of the Adult Social Care Outcomes Toolkit (ASCOT) measure of social care-related quality of life was developed to address the issues of wider inclusion of people with cognitive or communication difficulties who may otherwise be systematically excluded. The development of the proxy-report ASCOT questionnaire was informed by literature review and earlier work that identified the key issues and challenges associated with proxy-reported outcomes.

METHODS

To evaluate the acceptability and content validity of the ASCOT-Proxy, qualitative cognitive interviews were conducted with unpaid carers or care workers of people with cognitive or communication impairments. The proxy respondents were invited to 'think aloud' while completing the questionnaire. Follow-up probes were asked to elicit further detail of the respondent's comprehension of the format, layout and content of each item and also how they weighed up the options to formulate a response.

RESULTS

A total of 25 unpaid carers and care workers participated in three iterative rounds of cognitive interviews. The findings indicate that the items were well-understood and the concepts were consistent with the item definitions for the standard self-completion version of ASCOT with minor modifications to the draft ASCOT-Proxy. The ASCOT-Proxy allows respondents to rate the proxy-proxy and proxy-patient perspectives, which improved the acceptability of proxy report.

CONCLUSIONS

A new proxy-report version of ASCOT was developed with evidence of its qualitative content validity and acceptability. The ASCOT-Proxy is ready for empirical testing of its suitability for data collection as a self-completion and/or interview questionnaire, and also evaluation of its psychometric properties.

The Relationship Between Intelligence Quotient and Aspects of Everyday Functioning and Participation for People Who Have Mild and Borderline Intellectual Disabilities

BACKGROUND

This study explored the relationship between intelligence quotient (IQ) and aspects of everyday functioning/participation in individuals (age 16-40) who have a mild/borderline intellectual disability (IQ 55-85).

METHOD

Correlations were examined between IQ and (i) self-rated (n = 72) ability, participation as performance (how often an activity is performed), important participation restriction (not/seldom performing an activity perceived as important) and general well-being and (ii) proxy-rated (n = 41) ability and participation as performance.

RESULTS

No significant correlations between IQ and any of the explored measures were found. However, the effect sizes of the correlations between IQ and ability were considered as small but not negligible.

CONCLUSIONS

The results support the notion that IQ is a poor predictor of general aspects of everyday functioning in persons with mild/borderline intellectual disability. The result indicates that self-ratings partly generate other information than proxy ratings which may be important for assessments of supportive requirements and diagnosis.

Triangulated Proxy Reporting: a technique for improving how communication partners come to know people with severe cognitive impairment

PURPOSE

This paper explains and demonstrates the pilot application of Triangulated Proxy Reporting (TPR); a practical technique for enhancing communication around people who have severe cognitive impairment (SCI).

METHODS AND RESULTS

An introduction explains SCI and how this impacts on communication; and consequently on quality of care and quality of life. This is followed by an explanation of TPR and its origins in triangulation research techniques. An illustrative vignette explicates its utility and value in a group home for a resident with profound multiple disabilities. The Discussion and Conclusion sections propose the wider application of TPR for different cohorts of people with SCIs, their communication partners and service providers.

CONCLUSIONS

TPR presents as a practical technique for enhancing communication interactions with people who have SCI. The paper demonstrates the potential of the technique for improving engagement amongst those with profound multiple disabilities, severe acquired brain injury and advanced dementia and their partners in and across different care settings. Implications for Rehabilitation Triangulated Proxy Reporting (TPR) shows potential to improve communications between people with severe cognitive impairments and their communication partners. TPR can lead to improved quality of care and quality of life for people with profound multiple disabilities, very advanced dementia and severe acquired brain injury, who otherwise are very difficult to support. TPR is a relatively simple and inexpensive technique that service providers can incorporate into practice to improving communications between clients with severe cognitive impairments, their carers and other support professionals.

Validation of the Portuguese version of the Personal Outcomes Scale

BACKGROUND/OBJECTIVE

Quality of life (QOL) is actually helpful to organizations for guiding personalized support plans and enhance personal outcomes. However, there is a lack of consensus about the QOL construct in the field of intellectual disability (ID). This study aims (a) to analyze the first-order factor structure (i.e., eight domains) of the Portuguese version of the Personal Outcomes Scale (POS), and (b) to compare two alternative models of the higher factor structure of the QOL construct (i.e., Salamanca and Schalock).

METHOD

Both aims were investigated by examining self-report and report-of-others measures. Data were collected from 1,264 adults with mild or moderate levels of ID and respective proxies.

RESULTS

Results from confirmatory factor analysis (CFA) showed evidence of suitable psychometric properties of the QOL dimensions. Findings also highlighted that the first-order model was more robust than either of the two second-order models. Nevertheless, the Schalock structure was stronger than the Salamanca structure.

CONCLUSIONS

Although further research is needed, the results reveal that the Portuguese POS may be a valid and reliable instrument to measure QOL of adults with ID. The implication of these results are discussed highlighting the scale as a useful tool to serve as the basis for planning and evaluating personalized supports.

Brief Symptom Inventory symptom profiles of outpatients with borderline intellectual functioning and major depressive disorder or posttraumatic stress disorder: Comparison with patients from regular mental health care and patients with Mild Intellectual Disabilities

INTRODUCTION

In most countries, people with borderline intellectual functioning (BIF) are not considered a separate group in mental health care. There is little to no research on the impact of BIF on the presentation, nature and severity of mental health problems. The aim of the present exploratory study was to compare, in a naturalistic setting of patients referred to secondary care, symptom profiles of patients with BIF diagnosed with either major depressive disorder (MDD) or posttraumatic stress disorder (PTSD) to patients from regular mental health care (RMHC) and patients with Mild ID diagnosed with the same disorders.

METHODS

We used a cohort of adolescent and adult outpatients (aged 16-88) with or without BIF diagnosed with a primary diagnosis MDD or PTSD. Primary outcome was the nature and severity of psychopathological symptoms assessed at baseline using the Brief Symptom Inventory. All outcomes were adjusted for gender and age.

RESULTS

Results showed that BIF patients with a primary diagnosis MDD reported less severe symptoms on BSI Total and the subscales Depression, Obsession-Compulsion and Psychoticism than patients from regular mental health care (RMHC). There were no statistically significant differences in reported symptom severity on BSI Total and the different BSI subscales between BIF patients with PTSD and either patients from RMHC or patients with Mild ID. Patients Mild ID, did report significantly less severe symptoms on the subscale Depression and on the subscale Psychoticism than patients from RMHC.

DISCUSSION

Since there were no other published studies into symptom profiles in patients with BIF compared to either patients with higher or lower levels of cognitive functioning, the study was mainly exploratory in nature, providing direction for future research. Results indicate that symptom profiles did not widely differ, but that there might be some characteristics unique to patients BIF separating them as a group from both patients from RMHC and patients with Mild ID.

Deep Assessment: A Novel Framework for Improving the Care of People with Very Advanced Alzheimer's Disease

Best practice in understanding and caring for people with advanced Alzheimer's disease presents extraordinary challenges. Their severe and deteriorating cognitive impairments are such that carers find progressive difficulty in authentically ascertaining and responding to interests, preferences, and needs. Deep assessment, a novel multifaceted framework drawn from research into the experiences of others with severe cognitive impairments, has potential to empower carers and other support professionals to develop an enhanced understanding of people with advanced Alzheimer's disease and so deliver better calibrated care in attempts to maximize quality of life. Deep assessment uses a combination of techniques, namely, Behaviour State Observation, Triangulated Proxy Reporting, and Startle Reflex Modulation Measurement, to deliver a comprehensive and deep assessment of the inner states (awareness, preferences, likes, and dislikes) of people who cannot reliably self-report. This paper explains deep assessment and its current applications. It then suggests how it can be applied to people with advanced Alzheimer's disease to develop others' understanding of their inner states and to help improve their quality of life. An illustrative hypothetical vignette is used to amplify this framework. We discuss the potential utility and efficacy of this technique for this population and we also propose other human conditions that may benefit from research using a deep assessment approach.

Human rights of children with intellectual disabilities: comparing self-ratings and proxy ratings

BACKGROUND

A child rights-based approach to research articulates well with Article 12 of the United Nations Convention on the Rights of the Child (CRC) and highlights the importance and value of including children's own views about aspects that concern them. The aim of this study is to compare children with intellectual disability's own ratings (as self-raters) to those of their primary caregivers (as proxy raters) regarding human rights of children. The study also aims to establish whether there is an inter-rater agreement between the self-raters and proxy raters concerning Maslow's hierarchy of needs.

METHOD

This study is nested in a larger study examining the human rights of children with intellectual disability in South Africa. In total, 162 children with intellectual disability from 11 schools across three provinces and their primary caregivers participated by answering parts of a Children's Rights Questionnaire (CRQ) developed by the researchers based on the United Nation's CRC. We compared the answers for six questions in the questionnaire that were addressed to self-raters (children) and proxy raters (primary caregivers) in the same way.

RESULTS

Questions regarding basic needs, such as access to clean water or whether the child had food to eat at home, were answered similarly by self-raters and proxy raters. Larger differences were found when self-raters and proxy raters were asked about whether the child had things or friends to play with at home. Socio-economic variables seemed to affect whether self-raters and proxy raters answered similarly.

CONCLUSION

The results underscore the importance of promoting children's rights to express themselves by considering the opinions of both the children as self-raters and their primary caregivers as proxy raters - not only the latter. The results indicate that it is especially important to include children's own voices when more complex needs are surveyed. Agreement between self- and proxy ratings could be affected by socio-economic circumstances.

Operationalisation of quality of life for adults with severe disabilities

BACKGROUND

The operationalisation of quality of life for people with more severe disabilities has been acknowledged in the published research for more than two decades. This study aims to contribute to our knowledge and understanding of the quality of life of adults with severe disabilities by developing a set of quality of life indicators appropriate to this population using a Delphi method and the eight-domain conceptual model proposed by Schalock & Verdugo (2002).

METHOD

The participating panel in the Delphi method included 12 experts who evaluated each proposed item according to four criteria: suitability, importance, observability and sensitivity. Descriptive analyses were used to select the best items in each of the four rounds of this Delphi study, as well as examining the coefficients of concordance that were calculated for the final pool of items.

RESULTS

The four rounds of the Delphi study resulted in a final pool of 118 items (91 that were considered valid in the first round plus 27 items proposed, reformulated or discussed in the following rounds). Importance and sensitivity were the criteria that received the highest and lowest ratings, respectively, but also the ones that had the highest and lowest mean coefficients of concordance. Experts showed the strongest agreement for items related to material well-being, while the weakest was found for items related to personal development.

CONCLUSIONS

This study further contributes to our understanding of how to operationalise and measure quality of life in adults with severe disabilities. The item pool generated may prove helpful in the development of instruments for the measurement of quality of life-related outcomes in this population.

Proxy and self-reported Quality of Life in adults with intellectual disabilities: Impact of psychiatric symptoms, problem behaviour, psychotropic medication and unmet needs

Proxies often underestimate the subjective Quality of Life (QoL) of adults with intellectual disability (ID). However, little is known about the reasons for these differences. Accordingly, the purpose of the present study is to, firstly, compare the self-reported QoL of adults with ID with proxy reports from staff of sheltered working and housing facilities, and, secondly, to identify possible differences of the impact of four potential predictor variables. Data of 102 adults with ID were collected as part of the MEMENTA study ('Mental health care provision for adults with ID and a mental disorder'). Results show that self-report QoL scores ranged from 72.6 to 86.8. Both proxies consistently reported lower QoL scores and agreement between self and proxy ratings was predominantly poor. Unmet needs and psychotropic medication were identified as the most important predictors of reduced self-rated QoL, whereas an increase of psychiatric symptoms, problem behaviours, and psychotropic medication best predicted the reduced QoL proxy ratings. To conclude, proxies still have to strive for a more holistic approach in surrogate QoL assessments and according to adults with ID, service providers should focus on a reduction of unmet needs and psychotropic medication to further improve QoL.

Psychometric properties of the Spanish version of the Personal Outcomes Scale

Personal outcomes-related quality of life provides information about the impact of individualized supports and services that are provided to people with intellectual disability. The Personal Outcomes Scale (POS) is a valid and reliable instrument that measures these outcomes using two parts, self-report and report by others. Based on the POS, the aim of this study is to provide a new psychometric study of the instrument that allows the evaluation of the three principal informers involved in the enhancement of individual's quality of life: individual with intellectual disability, professional and family member. This approach overcomes the limitations of the POS. For the self-report were involved 529 people with intellectual disability. A professional (N = 522) and a family member (N = 462) separately participated for the report by others versions to assess personal outcomes for each participant. The reliability study provides appropriate values for the first and second order factors with α values being higher than .82. The construct validity analysis provides an adjustment of the theoretical model, particularly regarding the assessments from professionals. Results show this instrument is adequate to evaluate personal outcomes and giving the guidelines for making policy and practice decisions.